Postoperative care involves closely monitoring blood pressure, as about 50% of patients remain hypertensive for 3-4 days after tumor resection. Blood pressure typically returns to normal within 10 days as catecholamine levels stabilize. Pain management is also critical during this time. Options include narcotic infusions, patient-controlled analgesia (PCA), or epidural analgesia to minimize sympathetic stimulation and maintain stable hemodynamics. Patients are monitored in an intensive care or high-dependency unit for at least 24 hours for hypotension, rebound hypertension, and hypoglycemia. The newborn is observed for hypotension and respiratory depression when the mother received phenoxybenzamine. Plasma or urinary metanephrines are rechecked 2 to 6 weeks after surgery to confirm complete resection, genetic counseling and testing are offered, and lifelong annual biochemical surveillance follows because recurrence or a second primary can appear years later.
| Phase | Goal | Specifics |
|---|---|---|
| Alpha-blockade | Control hypertension and prevent crises during labor or cesarean delivery | Phenoxybenzamine (crosses the placenta; warn the neonatal team) or doxazosin started at least 10 to 14 days before surgery, with liberal salt and fluid |
| Confirming blockade | Verify preparation is adequate | Roizen criteria: no pressure above 160/90 mmHg for 24 hours; orthostatic hypotension present but standing pressure not below 80/45 mmHg; no ST-T changes for a week; no more than one PVC per 5 minutes |
| Beta-blockade | Control reflex tachycardia | Cardioselective agent added only after alpha-blockade, since unopposed α-adrenergic stimulation can produce dangerous hypertensive episodes; labetalol alone is inadequate |
| Volume | Correct the hypovolemia of chronic vasoconstriction | Fluid resuscitation to ensure adequate intravascular volume before surgery |
| Timing | Match the plan to gestational age | Before about 24 weeks: laparoscopic adrenalectomy in the second trimester after blockade; after 24 weeks: medical management, then resection at cesarean or a few weeks postpartum |
| Anesthetic choice | Blunt hypertensive surges and avoid abrupt sympathectomy | Epidural preferred for cesarean or vaginal delivery for its gradual sympathetic blockade; combined spinal-epidural also gives good hemodynamic control; avoid ketamine, ephedrine, pancuronium, atropine, metoclopramide, droperidol, succinylcholine, morphine and atracurium (histamine), high-dose desflurane |
| Intraoperative monitoring | Guide fluid management and detect surges | Continuous invasive arterial blood pressure and central venous pressure |
| Surges during tumor manipulation | Rapid blood pressure control | Nicardipine, nitroglycerin, or phentolamine 1 to 5 mg, plus magnesium sulfate 4 to 6 g then 1 to 2 g/h; esmolol for tachycardia; nitroprusside only briefly and at low dose (fetal cyanide) |
| After tumor removal | Treat hypotension from the sudden fall in circulating catecholamines | Stop vasodilators at vein clamping; fluid resuscitation with phenylephrine or norepinephrine; vasopressin if hypotension resists catecholamine-based treatment; oxytocin by slow infusion, no ergots; watch for rebound hypoglycemia for 24 to 48 hours |
| Postoperative | Continue blood pressure surveillance and limit sympathetic stimulation | ICU or high-dependency care for 24 hours; about 50% remain hypertensive for 3 to 4 days, normalizing within 10 days; narcotic infusion, patient-controlled analgesia, or epidural analgesia for pain; metanephrines rechecked at 2 to 6 weeks, genetic testing, lifelong surveillance |
